Provider Demographics
NPI:1326094871
Name:GEWOLB, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GEWOLB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2872
Mailing Address - Country:US
Mailing Address - Phone:201-339-0200
Mailing Address - Fax:
Practice Address - Street 1:830 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-2872
Practice Address - Country:US
Practice Address - Phone:201-339-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA034464002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4412155OtherPALMETTOGBA
NJ222264078OtherHORIZON BLUESHIELD
NJ2264078OtherOXFORD
NJ1014315Medicaid
NJ222264078OtherQUALCARE
NJ222264078OtherHORIZON BLUESHIELD
NJ1014315Medicaid